How many times can an insuance company reprocess a claim?

Posted: Wed Nov 12, 2008 2:38 pm Post subject: How many times can an insuance company reprocess a claim?

I work for a dr. in Ohio. We are having a problem with an insuance company. How many times can an insuance company reprocess a claim? We have a specific group of patients that have been processed no less than 3 times for a specific group of dates of service. I have a pile of 100+ pages of mess. Every week I get a new EOB with a new problem. They take back money they have paid, combine services, reprocess and then sometimes pay again incorrectly. So then that creates a traking/paperwork nightmare! I have no idea what to do and how to handle this. I have called my provider rep and she says that they have it taken care of. It started because they processed two units as only one...then this snowballed into reprocessing with correct 2 units. Accidentally paying too much on some patients, then reprocessing again taking back other services on same day (saying they were secondary to primary procedure) then processed again as duplicates and so on...Such a mess. Now they are going back up to 2 years ago so far and reprocessing again creating themselves an accounts receivable. If you can help....please do.

lordandlife7, understand (kind of) your problem, and help should be on the way. I'm close to a person who does this all the time, and she's really good at her job. I sent her your question, and she should reply soon.

I know she's going to ask me to see if I can get you to be a little more specific. I know a little about medical claims processing, but certainly not enough to be of much help. Can you give me a brief synopsis of what has occurred? Don't violate any laws or ethics, just give me something that someone else in your job would know how to interpret, and I think I can get you some good help.

Thanks, and good luck with the paperwork nightmare. I use to hear about it all the time from her until she learned her little insurance tricks!

This whole process sounds very weird to me. I'm not aware that an insurance company can actually take the money back that is once paid towards the claim I'm sure some experience community member will be soon around with the solution. Just hang tight.

Ok so...this is how it goes.
Patient A. DOS: 12/27/2007 svcs 98940 or 98941 $40.00 1 unit (depends on patient), also svc 97124-59 (was different area than manip so ok to bill modifier) anyhow, 97124-59 $60.00 2 units. When the claim came back from being processed they only paid 98940/1 and one unit of 97124-59. But then for the next 6 weeks this problem came in on 15-20 different patients. So I gathered up all the mess so far called BCBS and talked to their cust. svc she and I sat on the phone for over 1 1/2 hours she said she corrected it. Well then the EOB's rolled in that they reprocessed these claims. They took away (created an Accounts Receivable AR) all the payments for code 98940/1 with the expl. This procedure is considered redundant to the primary procedure. Part of the problem with these is that when they "corrected" the problem they also paid the correction incorrectly. I understand the $10 dollars AR for that but not all the others. This is a specific problem for a specific group of patients. Once this group of patient problem started in DEC/JAN then in APRIL they started processing this group as not having effective insurance. This inturn has started another group of problems. Because now, this APRIL problem has kicked off another group of AR's. It is not all BCBS members. It is not all members of Anthem. It is however all blue card members of BCBS. This has turned into an extraordinary mess. As you can see it has been going on for a year. They have created AR's for back to 2006 on some people.
Every year, usually in January BCBS or another insurance pulls some major fiasco to not pay correctly. I have to say this is the ultimate. There is no way to keep track of what they are taking, paying, processing and so on because of the way the EOB's read. This is a huge paperwork nightmare. I have stopped putting them in our software system to keep track of what is paid and not because at this point I have no idea. I am not even sure you will be able to help me. I appreciate your time and head scratching on this.... really. Thanks.

I'm not aware that an insurance company can actually take the money back that is once paid towards the claim

Sure they can, in most cases, if there has been an overpayment.

_________________"Never, never be afraid to do what's right, especially if the well being of a person or animal is at stake. Society's punishments are small compared to the wounds we inflict on our soul when we look the other way." Martin Luther King Jr.

Hi again, lordandlife7. I got a response from my expert, and the information that she told me was just about what I thought as well. This is going to be one of those "grind it out" with the insurer kind of things.

Here's what she said in response to your questions:

Quote:

What this person needs to do is call the insurance company and get a supervisor on the phone to handle this. It sounds like something I just went through with a company. I spent a good hour on the phone with the supervisor and got everything squared away. This person needs to have all claims in front of them and needs to let the supervisor know that it is going to take time.

Important to make sure you get a supervisor, have all of the paperwork, and let the supervisor know that this conversation you're about to have is going to take a while to sort through. Had a feeling that was going to be the response. I will keep her in the loop as the thread progresses.

Gosh....sounds complicated, for sure!! I think COFFEEANDCARAMEL 'nailed' it. The insurance company should have 'sorted through' the claim BEFORE giving out the payment. If they didn't, that's THEIR fault........an error on THEM. So......basically, what is being said, 'we' have to pay for THEIR error?! How crazy.

This has been happening at my dentist office so much lately. My insurance company keeps denying payment because they will say the procedure code and tooth do not match. The dentist will change it and then here we go again ..another reason..I am worried that it can only be reprocessed so many times before we are liable to pay when we have great coverage. Is there an actual number to how many times a claim can be reprocessed?

According to the Ohio Insurance Commision Insurance companies have uo to 2YEARS to request money back for an overpayment for "erroneous errors." They also have the right to turn over to collection if you do not return the requested overpayments or collect it from any outstanding payments as yet not paid to you. As a provider you have the right to dispute a claim, you have the right to expect payment in 90 days or bill for the interest but guess what you have to pay the commission a fee for them to assist you with that. A lose lose for the provider! Thank your lawmakers, probably the same group that thought HIPPA protected pts when it really just created more provider problems and lessened confidentiality.